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Консультант врача

Электронная медицинская библиотека

Раздел 7 / 16
Страница 1 / 9

5. OBSTETRIC AND GYNECOLOGICAL HISTORY

This section of the medical history always starts with description of the patient's menstrual function. Its description includes the age of the first menstruation (menarche), cycle settling time, menstruation and cycle duration, painfulness, amount of blood loss (poor, moderate, heavy), changes in the menstrual cycle after delivery, abortions, gynecological disorders, type of the menstrual dysfunction). Date of the last menstruation.

Example. Menstruation started at the age of 14 (cycled settled from the first menstruation), duration is 4-5 days, once in 28 days, menstruation is regular, with moderate blood loss, painless. The first day of the last menstruation was March 06, 2017.

Menstruation started at the age of 18, cycle settled in 2 years. At present (after spontaneous miscarriage), menstrual bleeding lasts 6 days, once in 28-60 days, menstruation is moderate, painful. Pain management is performed with non-steroid anti-inflammatory medications (pentalgin, nurofen), spasmolytics (no-spa).

Description of sexual function includes the age of sexual activity onset and contraceptive methods (barrier, hormonal, symptothermal method, coitus interruptus, not used).

It is followed by a detailed description of the gravida's reproductive performance. It shall necessarily contain the year, duration and outcome of each pregnancy (abortions, miscarriages, ectopic pregnancy, delivery) in the chronological order. Thus, information about induced abortions shall contain the gestational age, at which the abortion took place, indications (medical, social or at patient's will), methods, complications. Description of spontaneous miscarriage shall contain the gestational age, at which the miscarriage took place, treatment and its complications. In case of ectopic pregnancy its location, methods of surgical treatment and complications shall

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